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Slide 13

Slide 14

For all diseases, that which is clinically apparent without "looking beneath the surface" is just the tip of the iceberg.

Slide 15

Looking Beneath the Surface

"Early detection" could be interpreted as a heightened awareness of those people above the surface with early manifestations of disease - I will call that case finding - and I will not address today

But, "early detection" more often implies looking beneath the surface - I will call that screening

Slide 16

Looking Beneath the Surface

What are the six possible outcomes of screening?

Slide 17

Looking Beneath the Surface: Screening Outcome #1

Screening test negative.
- but the patient has the disease - false negative - inappropriately reassured
- Ignoring a new breast lump because mammogram was normal

Slide 18

Looking Beneath the Surface: Screening Outcome #2

Screening test negative and the patient does not have the disease
- True negative. No health benefit since patient does not have the disease

though patient reassured - is that always good?

- Is screening fatigue real?

Slide 19

Looking Beneath the Surface: Screening Outcome #3

Screening test positive...
- But patient does not have disease

false positive - subject to risks/costs of further testing and anxiety

e.g. maternal serum testing for Down syndrome/Trisomy 18 is calibrated to label 5% of women abnormal

Slide 20

Looking Beneath the Surface: Screening Outcome #4

Screening test positive and patient does have disease.
- but is not destined to suffer morbidity or mortality related to the disease

treated unnecessarily

e.g. 25% of men in age range for prostate cancer screening have prostate cancer. Life time risk of death is 3%. How many of those detected by screening are treated for disease that would never have made it to the surface?

Slide 21

Looking Beneath the Surface: Screening Outcome #5

Test positive and the patient is destined to suffer morbidity or mortality related to the disease
- but outcomes of treatment in asymptomatic stage are no different from treatment after symptoms are present

we simply lengthen the treatment time

e.g. what morbidity do we really prevent by screening for COPD with spirometry?

Slide 22

Looking Beneath the Surface: Screening Outcome #6

Test positive
- Patient destined to suffer morbidity or mortality related to the disease - and treatment in asymptomatic stage prevents complications that would develop if treatment not started until after symptoms are present
- e.g. screening for colon cancer and treating in asymptomatic stage has clearly been shown to save lives

Slide 23

Screening Outcomes: Keeping Score?

For 5 of 6 outcomes, there can be NO health benefits to the patient
- These 5 outcomes are not just costly - patients incur the harms of screening and treatment

For 1 of 6 outcomes, there can be health benefits to the patient,
- but no assurances that the benefits will exceed the harms of screening and treatment across screened populations

Slide 24

We should screen when good evidence demonstrates that the benefits of detection of a disease in an asymptomatic phase exceed the harms associated with diagnosis and treatment across screened populations

Slide 25

Analytic Framework on Screening for a Disease: What Evidence Do We Seek?

Slide 26

USPSTF Recommendations

The TF judges whether the strength of the available evidence is sufficient to make a reliable assessment of the balance of benefits and harms

If yes - then TF makes recommendation

If no - "I" (insufficient evidence) statement
- Common reasons:

Lack of evidence on clinical outcomes

Poor quality of existing studies

Good quality studies with conflicting results

Slide 27

Grades of Recommendation

Slide 28

June 29, 2008
NY Times

"It's incumbent on the community to dispense with the need for evidence-based medicine," he said. "Thousands of people are dying unnecessarily."

Slide 32

routine Pap smear screening in women who have had a total hysterectomy for benign disease

Prostate cancer in men age 75 years or older

Slide 33

We are swimming upstream
(to lay eggs and die)

Slide 34

The forces for providers to "do" are enormously greater than the forces to "not do"

Slide 35

Forces To "Do"

A noble ambition to do good, and the failure to recognize (or the ability to ignore) harm

Miss Saigon
- "So I wanted to save her, protect her Christ, I'm American, how could I fail to do good?"
- "So I wanted to save her, protect her Christ, I'm a doctor, how could I fail to do good?"

Slide 36

Forces To "Do"

A cultural expectation that medical care can only do good, not harm, and that more care is always better than less

The public and the medical profession have faith in technology

Slide 37

Slide 37. Screening should not be a faith-based initiative.

Screening should not be a faith-based initiative

Slide 38

Forces To "Do"

The American Cancer Society

There are disease advocacy organizations that have substantial sway over the opinions of the public and medical profession

Slide 39

Forces To "Do"

Fear of litigation

"Failure to detect"

Slide 40

Forces To "Do"

Quality Measures

Current PQRI quality measures include 13 specific measures that include the word "screening"

Every one requires screening

Not one single measure addresses use of unnecessary screening services

Slide 41

Forces To "Do"

Payment

"Every dollar spent on health care is a dollar of income for someone"

In the debates of health care reform past (and perhaps present): it is "immoral" to pay physicians to "withhold care"

Slide 42

What Not to Do in Primary Care: Overuse of Preventive Services

If "Prevention" translates to unbridled use of early detection (a.k.a. screening), then in the process of promoting prevention we will do much harm and health care costs will increase.

Slide 43

Screening

We should screen when good evidence demonstrates that the benefits of detection of a disease in an asymptomatic phase exceed the harms associated with diagnosis and treatment across screened populations

Slide 44

Steps Forward

The national conversation needs to change

I think it is changing

All change is perceived as loss by someone

Current as of December 2009

Internet Citation: What Not to Do in Primary Care: Overuse of Preventive Services (Text Version).
December 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://archive.ahrq.gov/news/events/conference/2009/lefevre/index.html

The information on this page is archived and provided for reference purposes only.